ABSTRACT
RATIONALE: The outcomes of patients with COVID-19 who are medically eligible to receive ECMO, but do not because of limited health system capacity, have not been reported. METHODS: We analyzed prospectively collected clinical data from consecutive patients with SARS-CoV-2 referred for ECMO to a single center between January 1, 2021 and August 31, 2021. Each patient underwent a systematic assessment of medical eligibility to receive ECMO followed by a separate assessment of the health system's resources to provide ECMO. When health system resources were available, the patient was transferred to an ECMO center. When health system resources were not available, the patient was not transferred to an ECMO center and did not receive ECMO. Patients were followed until the time of death or hospital discharge. Among medically eligible patients, we compared those for whom health system capacity permitted transfer to receive ECMO to those for whom health system capacity did not permit transfer to receive ECMO with regard to the primary outcome of all-cause in-hospital mortality using Cox proportional hazards regression analysis adjusting for age, acute kidney injury, and receipt of vasopressors. RESULTS: Among the 240 patients with COVID-19 referred for ECMO, 90 patients (37.5%) were determined to be medically eligible to receive ECMO and were included in this study. Median age was 40 years (IQR, 34-48). The health system capacity to provide ECMO was available for 35 patients (38.9%), of whom 32 received ECMO and 3 died or developed a contraindication to ECMO after transfer but prior to cannulation. Death before hospital discharge occurred in 15 of the 35 patients (42.9%) for whom health system capacity permitted transfer to receive ECMO compared with 49 of the 55 patients (89.1%) for whom health system capacity did not permit transfer to receive ECMO (adjusted hazard ratio 0.23;95% confidence interval, 0.12 to 0.43;P < 0.001) (Figure 1). CONCLUSIONS: In this cohort of adults with COVID-19, nearly 90% of patients who were eligible for ECMO but did not receive it due to limited health system resources died before hospital discharge, despite young age and limited comorbidities. Periods of resource limitation during which provision of ECMO is determined by resource availability and not patient characteristics may act as a natural experiment, and these results suggest that ECMO provides a significant mortality benefit in the treatment of COVID- 19.
ABSTRACT
Lung transplant (LTx) recipients have increased risk of infection with SARS-CoV-2 and have reduced efficacy from COVID-19 vaccination. The Delta variant of SARS-CoV-2 has increased virulence compared to earlier variants. We hypothesized that LTx recipients would have increased susceptibility to Delta variant infection despite vaccination. We performed a retrospective cohort study of 314 LTx recipients followed between 1/1/2020-9/30/2021. Diagnosis of SARS-CoV-2 infection by PCR was recorded;Delta variant comprised >99% of strains from 6/1/2021-9/30/2021. Data regarding COVID-19 vaccination status, symptom development, hospitalization, intubation, and death were collected. Forty-four patients (14%) were diagnosed with COVID-19, 18 (41%) of which were Delta variant. The rate of infection with Delta was 4-fold higher than with earlier strains (Figure, 0.016 vs. 0.004 cases / patient months, p<0.001). Fifteen (83%) patients diagnosed with Delta variant were fully vaccinated at the time of infection (p<0.001). The rate of infection with Delta variant in vaccinated and unvaccinated individuals was similar (0.017/patient months with vaccine, 0.015/patient months without vaccine, p=0.84). The majority (>89%) of patients had respiratory symptoms in both groups. More patients with Delta variant received monoclonal antibody infusions (89% vs. 54%, p=0.021) and fewer patients with Delta variant had resolution of disease (50% vs. 92%, p<0.001). There was a trend towards greater O 2 needs with Delta variant (p=0.07). Hospitalization (38% vs. 23%), intubation (11% vs. 4%), and death (11% vs. 4%) were numerically greater with Delta variant, although not statistically significant. The incidence rate of SARS-CoV-2 infection was significantly greater with Delta variant in LTx recipients, despite high prevalence of full vaccination during the Delta wave. Further study in larger cohorts is needed to determine whether booster vaccines can reduce such infectivity. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)